Screening: New guidance on what and what not to do

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Practice Alert

Screening: New guidance on what and what not to do

J Fam Pract. 2007 June;56(6):461-463

By

Doug Campos-Outcalt, MD, MPA

The entity with the most rigorous evidence-based approach is the US Preventive Services Task Force.

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References

1. USPSTF. Screening for iron deficiency anemia—including iron supplementation for children and pregnant women. Available at: www.ahrq.gov/clinic/uspstf/uspsiron.htm. Accessed on May 17, 2007.

2. USPSTF. Routine aspirin and nonsteroidal anti-inflammatory drugs for the primary prevention of colorectal cancer. Available at: www.ahrq.gov/clinic/uspstf/uspsasco.htm. Accessed on May 17, 2007.

3. USPSTF. Screening for colorectal cancer. Available at: www.ahrq.gov/clinic/uspstf/uspscolo.htm. Accessed on May 17, 2007.

4. USPSTF. Screening for hemochromatosis. Available at: www.ahrq.gov/clinic/uspstf/uspshemoch.htm. Accessed on May 17, 2007.

5. USPSTF. Screening for developmental dysplasia of the hip. Available at: www.ahrq.gov/clinic/uspstf/uspshipd.htm. Accessed on May 17, 2007.

6. USPSTF. Screening for elevated blood lead levels in childhood and pregnant women. Available at: www.ahrq.gov/clinic/uspstf/uspslead.htm. Accessed on May 17, 2007.

7. USPSTF. Screening for speech and language delay in preschool children. Available at: www.ahrq.gov/clinic/uspstf/uspschdv.htm. Accessed on May 17, 2007.

One of our key responsibilities is to provide effective preventive services—and avoid performing tests of no value. Since most of us do not have time to keep up with the literature on what services and tests have and have not been proven effective, we depend on trusted authorities to make these assessments for us.

The entity with the most rigorously evidence-based approach is the United States Preventive Services Task Force (USPSTF). (TABLE 1 lists the criteria for their recommendations.) Every year, this Practice Alert summarizes the new recommendations from the task force. The new recommendations in the 6 disease categories discussed here were published by the USPSTF in 2006 and the first quarter of 2007 (TABLE 2).

Iron deficiency anemia
Colon cancer chemoprevention
Genetic screening for hemochromatosis
Congenital hip dysplasia
Elevated lead levels
Speech delay

TABLE 1
The rigor behind the recommendations

RECOMMENDATION	EVIDENCE	RESULTS OF THE SERVICE
A Strongly recommends	Good evidence	Improves important health outcomes Benefits substantially outweigh harms
B Recommends	At least fair evidence	Improves important health outcomes Benefits outweigh harms
C No recommendation	At least fair evidence	Can improve health outcomes Balance of the benefits and harms is too close to justify a general recommendation
D Recommends against	At least fair evidence	Ineffective, or Harms outweigh benefits
I Insufficient evidence	Insufficient to recommend for or against	Evidence that the service is effective is lacking, of poor quality, or conflicting, and Balance of benefits and harms cannot be determined

TABLE 2
Summary of new USPSTF recommendations

B RECOMMENDATIONS
*The USPSTF recommends* routine:** Screening for iron deficiency anemia in asymptomatic pregnant women Iron supplementation for asymptomatic children ages 6 to 12 months who are at increased risk for iron deficiency anemia
D RECOMMENDATIONS
*The USPSTF recommends against* routine:** Use of aspirin and nonsteroidal anti-inflammatory drugs (NSAIDs) to prevent colorectal cancer in individuals at average risk for colorectal cancer Genetic screening for hereditary hemochromatosis in the asymptomatic general population Screening for elevated blood lead levels in asymptomatic children ages 1 to 5 years who are at average risk Screening for elevated blood lead levels in asymptomatic pregnant women
I RECOMMENDATIONS
*The USPSTF concludes that evidence is insufficient* to recommend for or against routine:** Screening for iron deficiency anemia in asymptomatic children ages 6 to 12 months Iron supplementation for asymptomatic children ages 6 to 12 months who are at average risk for iron deficiency anemia Iron supplementation for non-anemic pregnant women. Screening for developmental dysplasia of the hip in infants as a means to prevent adverse outcomes Screening for elevated blood lead levels in asymptomatic children ages 1 to 5 who are at increased risk Brief, formal screening instruments in primary care to detect speech and language delay in children up to 5 years of age

“I” means insufficient evidence

As usual, there are many screening tests that lack evidence either for or against their effectiveness. The Task Force places such tests in the “I” (insufficient evidence) category. Physicians should remember that an “I” recommendation is not the equivalent of a “D” (recommend against).

Screening implies routine testing, and no symptoms

We also need to keep in mind the difference between screening and diagnosis. Screening implies routine testing among asymptomatic patients. Screening recommendations do not apply to symptomatic patients in whom diagnostic testing may be indicated.

1. Iron deficiency anemia

The task force recommends

routine screening for iron deficiency anemia in asymptomatic pregnant women, and
iron supplementation for asymptomatic children ages 6 to 12 months who are at increased risk for iron deficiency anemia.¹

The task force concludes that the evidence is insufficient to recommend for or against

routine screening for iron deficiency anemia in asymptomatic children ages 6 to 12 months,
iron supplementation for asymptomatic children ages 6 to 12 months who are at average risk for iron deficiency anemia,
iron supplementation for nonanemic pregnant women.¹

Iron deficiency anemia is linked to developmental and cognitive abnormalities in children and poorer birth outcomes in pregnant women. The task force felt that the weight of the evidence supports a set of recommendations that includes screening all pregnant women and using iron preparations for those who have deficiency, and using routine iron supplementation for at-risk infants between the ages of 6 and 12 months.

FAST TRACK

The evidence is “at least fair” that iron supplements benefit infants from low socioeconomic backgrounds and premature infants

The lack of a recommendation on screening all children was based on concern about the accuracy of hemoglobin as a screening test for iron deficiency and a scarcity of evidence that universal screening results in improved outcomes. Routine iron supplementation was felt to be of proven benefit only for infants at increased risk: those from low socioeconomic backgrounds and premature and low birth weight infants.

The Centers for Disease Control and Prevention (CDC) agrees that screening should be performed in high-risk infants and all pregnant women, but recommends universal iron supplementation during pregnancy.

Screening: New guidance on what and what not to do

References

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